mental health nurse and managing emotions...

Mental Health Nurseand

Managing Emotions Program

Who are you?

1. Campus physician2. Mental health nurse3. Campus counsellor4. other campus staff5. other

Do you have a full time dedicated Mental Health Nurse?

1 – Yes2 – No

Our online search found 15 (6%) of 243 Canadian post secondary institutions have

only nurses or nurse practitioners providing medical care on campus!

Mental Health Nurse was the main request of our

clinic psychiatrists.

Role of the Mental Health NurseCathy Buchan, BScN

1. Crisis Triage and Assessment• Assess risk and needs• Develop care plans

– Goal setting – Develop coping strategies – Teaching to communicate re health issues

• Sign consents to request old medical records• Help complete Requests for Academic

Concession

2. Care Coordination

1. within clinic2. on campus

• Regular collaboration with Counselling, Resource Centre for Students with Disabilities, Residence and Case Managers (with Judicial Affairs)

• Follow up of reports from campus security

3. with community• Reports to and from local community hospital and

services

2. Care Coordination

217128

208

657

389

629

1400

614 602

0

200

400

600

800

1000

1200

1400

1600

Within Clinic Campus Community (includes pt.

calls)

Mental Health Nurse Interactions

*Sep 2015 Oct - Dec 2015 Jan - April 2016

Care Coordination

3. Support patients between visits to physicians assessing risk

• Suicide • Self harm • Physical risk (ED) • Responses to

medication • Pending psychosis

4. Programs

• Diabetes and Depression Focus Group• Eating Disorders• Managing Emotions

Eating Disorders Program

• Program intakes - 58 in 2016-17• Monitor and follow illness• Delegate to and coordinate clinicians • Liaison between practitioners• Maintain updated records of the status of

all patients for the team• Leads team meetings every other week

3 8

2910

25

88

45

14

117

0

20

40

60

80

100

120

140

Numbers of Encounters by MH Nurse

*Sep 2015 Oct - Dec 2015 Jan - April 2016

Eating Disorders Managing Emotions In Clinic

Intakes Other 1:1

Managing Emotions Program

• Intakes - 47 in 2016-17 • Correspondence about program with

students• Plan and Co-Lead “Advanced Identity and

Mindfulness”• Co-lead the Foundations ME Group – not

ideal

5. LiaisonFamilies

– Support and counsel– Mental health education– Inform about returning to school procedures– Advise on accessing health system access

Professors– Inform about accessing UHS – advise on managing a student’s difficulty – Coaching on assessing risk

6. Debriefing and Supporting Staff

Most patients rated the MH Nurse positively

0 25 50 75 100

I felt understood

She responded to my crisis or urgent needs

I felt more hopeful as I left

I would recommend this type of appointment for someone with my trouble

I had a good understanding of my support plan

The services I received have helped me deal more effectively with life's challenges

% Agreed or Strongly Agreed

34% 66%

-5 5 15 25 35

Number of StudentsN = 29

Not Helpul Mildly Helpful Very Helpful

Mental Health Nurse

All of the student respondents found the Mental Health Nurse Helpful

The position was invaluable to all staff

100% gave it the highest ratings possible.

Having a designated MH nurse is a no

brainer!

Our busy MH nurse

For a campus of 21,700,

2 MH nurses were required

Paper in progress showing…

• 52 Nursing Interventions Classification (NIC) skills

• Case management inseparable from MH nursing role (as is true in other papers about the MH nurse’s role)

Questions?

Switchingtopics…Ismanagingortreatingindividualswithborderlinepersonalitytraits/disorderasignificantissueforyourcampus?1– Rarely2– Monthly3– Weekly4– Daily5– Noideawhatyoumean

DoyouhaveDBTorsomethinglikeitoncampus?

1– Yes,managedbyUniversityHealth2– Yes,managedbyCounselling3– Bothoftheabove4– No,werefertoanexternalprograminthecommunity5– No,andnothingisavailableinthecommunity

AtUVicUniversityHealthServices:• <1%ofGP’smentalhealthpatients

• 22%ofpsychiatrists’patients

PIT Project’s Experience with Implementing a

Managing Emotions Program

ErinBurrell,CathyBuchan,DawnOlson,MarilynThorpe

Purpose of Managing Emotions Program

• To improve participants capacities to manage their emotional experiences through the learning and practice of practical acceptance and change strategies

• To equip participants with tools and strategies that enable them to respond to triggering events and life situations with thoughtful choices

Theory and Approach• Managing Emotions (ME) draws primarily on

DBT Theory • DBT views central problem in emotional

dysregulation as a skill deficit arising from childhood emotional invalidation combined with inherent emotional vulnerability

• Therefore, ME program is firmly oriented toward skills training. This also serves fact of limited availability of resources

• ME is NOT a process group• One therapy (therapist) per student

• Baer, R. (2014). The practicing happiness workbook: How mindfulness can free you from the four psychological traps that keep you stressed, anxious, and depressed. New Harbinger Publications.

• Linehan, M.M. (2014). DBT skills training manual, second edition. Guilford Press.

Three Trained Therapists• Program requires three staff – two

facilitators and one mental health nurse• Each of the three needs a minimum 30

hours DBT training • Lead facilitator needs minimum two years’

experience facilitating DBT groups with proven mastery of DBT skills and concepts, and managing participant behaviours

Criteria and Rationale for Participant Selection

MEcriteriaformulatedto:•Ensurelowdropoutrates•Protectwell-beingofparticipants(moreseverecopingdifficultiesrequiremoreintensivecarethanMEmodulesprovide)

ME Inclusion Criteria

• Problems with emotional regulation & counterproductive behaviours (avoidance, self-harm etc.)

• Motivated to complete course & practice skills

• Agree/capable not to self-harm• Can appropriately participate in group

discussions and activities

ME Exclusion Criteria

• Psychosis• Cognitive/language difficulties that

interfere with use of group materials• Violent/aggressive behavior• Active suicidal behaviours • Actively using substances that would

interfere in learning or affect others in the group

x

University of Victoria Managing Emotions Program•Offered monthly, 60 minute presentation•Overview of symptoms, causes, Borderline Personality Disorder, PTSD, diagnosis, treatment

•Distribution of intake packagesInformation Session

•Referral from family doctor•Approximately 1 hour with Mental Health Nurse•Review of completed intake package & suitability assessment•$ deposit for Foundations Module

Intake Appointments

• Six sessions – 1 hour and 45 minutes each • Offered each semester• Introduces: Mindfulness, Emotion Regulation and Distress Tolerance concepts and skills

• Is a prerequisite to all advanced modules

Foundations Module

•Modules are independent and can be taken in any order•Six sessions – 1 hour and 45 minutes each•Each Advanced Module is offered once per year

Advanced Modules

Distress Tolerance

Mindfulness and Establishing Identity

Advanced Managing Emotions

Interpersonal Effectiveness

Steps to preparing Clinic Staff for Managing Emotions Program

• Present ‘Student Introductory ME Lecture’ to physicians and nurses with questions and discussion to follow

• Present ‘Orienting Doctors and Nurses to DBT Theory and Skills’ powerpoint to clinic staff, with questions and discussion to follow

• Provide doctors and nurses with ‘Top Ten DBT Skills’ in-office tool for their use with ME patients

Educating Students about Managing Emotions

Students who are interested in ME are provided with a one page handout that describes:

• How ME can help them change their relationship with their emotions

• The structure and approach of ME group–more of a ‘class’ than a ‘therapy group’

• How to tell if ME might be a good fit for them• Next steps in learning more about ME,

determining their eligibility for the program, and signing up

Mandatory Intake Process

Interested students are required to:• Attend the introductory student lecture

Introductory Lecture

Mandatory Intake Process

Interested students are required to:• Attend the introductory student lecture. • See their GP to discuss and be referred.• Complete intake forms (re: program fit,

strengths, emotional troubles, motivation, goals).

• Arrange for and attend intake appointment.• Following this, if meet criteria, pay $60.

Focus of Assessment at ME Intake• Evidence that emotional dysregulation is the

primary mental health concern – History – ‘What is troubling you?’ list – GP referral note

• Motivation / capacity to attend and learn -> – attends appointment, arrives on time– intake forms are complete

• Client readily identifies with purpose and content of program, and seems keen.

• Evidence (interview, forms, GP) that client will contribute to (rather than detract from) positive group experience.

Clear, Firm ME Boundaries• Attendance requirements are clearly stipulated

and no exceptions are made for any reason– e.g. one session only of Foundations module may be

missed, or entire module must be repeated.• Group begins/ends right on time.• A group agreement is reached through review and

discussion of behaviours that are acceptable/not acceptable, including phones, fidgeting, eating/drinking, etc.

• References or allusions to self-harm, suicide, and other destructive behaviours are not permitted, but may be referred to as ‘my trigger behaviour’.

Monitoring of Group Members• Check in –focused on homework review but may

include major events/issues• Check out – for a sense of how participant is doing• Self-progress reports – limited space (intentional)

contributes to picture of how participant is doing• Post session check - any participant who hasn’t

spoken up or where there is concern (relatively rare)

• Regular visits strongly encouraged with GP • Facilitators’ debrief sharing observations• MH Nurse follow up, by facilitator request, with

participant of concern

TheStoryofMariko

OverviewofDBTSkillsandConceptsTaughtinManagingEmotionsIllustratedThrough…

MindfullyObservingandDescribing

EmotionshaveUrges,Sensationsand

Thoughts

LabellingEmotions

OneBreathSkill

‘BeingMind’and‘FindingthePause’

TheWorkabilityzoneontheEmotionalIntensityDial

https://www.divisionsbc.ca/victoria/CBTskillsgroup

EmotionsareValid

MindfulnessBirdanditswingofAcceptance

- BirdanalogyfromTaraBrach,mindfulnessteacher

JustifiedEmotions

ActingonEmotionalUrges

onlyifitisHelpfulandEffective

todoso

ValuesandGoals

OppositeActionalltheway

AcceptanceandWillingness

‘HalfSmile’‘WillingHands’

Respondingratherthan

Reacting

Practices that Increased Effectiveness of Group

• Starting every session with 1 or 2 minute mindfulness practice

• Contained, brief check in/out – one word/one sentence, for e.g. “If I were a car, I’d be a…because…”

• Homework completion increased through – 1) linking h/w to skills of acceptance &

willingness – 2) having participants set homework goals

Practices that Increased Effectiveness of Group

• Self-progress notes: – 1) seemed more informative – 2) provided increased sense of personal

responsibility

Observation: Groups seemed to ‘form’ in about session 4 of module – increase in confidence, reduction in symptoms with successful use of skills, increase in group energy

One Year of Managing Emotions

# of students

107 On our radar

76 (71%) Attended Intro lecture

47 (44%) Intakes

7 Inappropriate

36/40(34% / 37%)

Finished Foundations Module

5/5 Finished Advanced Distress Tolerance Module

4/5 Finished Identity and Mindfulness Module

Evaluating the ME Program

• DERRS• UHS Feedback Form• UHS Self-progress Reports

I am confident handling my emotions

Scale of 1-10 (Average score of group members)• Prior to group 3• After Foundations 7

The practical skills helped me take control of my

overwhelming emotions.

Getting to be more comfortable with the group over the period of the 6 sessions, a sense of belonging was fantastic in a nervous group like that.

It gets me actively engaging in skills that are new, or that I had

learned before, such that I actually integrate them into my

life and lifestyle.

Patient comments:

Forsomanyyears,IdreadedthesepatientsandsentthemawayquicklybecauseIfeltoverwhelmed….NowIunderstandthemandIamexcitedtheywillgetbetter….IlookforwardtotheirvisitsbecauseIunderstandthattalkingandbeingunderstoodisimportant.

Familydoctor’scomment:

ProjectTeam(PitCrew)Members

FundingforthisinitiativewasprovidedforbytheSpecialistServicesCommittee(SSC), oneoffourjointcollaborativecommitteesrepresentingapartnershipof DoctorsofBCandtheBCMinistryofHealth.

SECONDARYDr.AndreKushniruk – Co-InvestigatorDr.ElizabethBorycki – Co-InvestigatorDr.Judy Burgess– ClinicDirectorDr.LeighGreiner– DataAnalyst

COREDr.MarilynThorpe– ProjectLeadHelenMonkman– ProjectManagerDr.E.Burrell– CreatorofFoundationsDawnOlson– CBTTherapist,CathyBuchan– MHNurseDr.J.Cheek– originalworkTheresaBrown– MOAforMentalHealthDr.OonaHayes– GPMentalHealthLeadDr.JamesFelix– GPMentalHealthLeadJuneSyracuse– Counselling,Facilitator

CONTACTINFORMATIONFORWEBINARSJaworska,DeSomma,Fonseka,Heck,MacQueenMentalHealthServicesforStudentsatPostsecondaryInstitutions:ANationalSurvey,CanJPsychiatry. 2016.61(12):766-775

FAMILYDOCTORSDr.S.Baskerville-BridgesDr.J.BowlesDr.M.BrydonDr.W.DysonDr.B.FraserDr.K.FosterDr.J.FryDr.C.GrayDr.T.GarnettDr.J.KimDr.C.LeviaDr.S.MartinDr.B.MeekerDr.S.StewartDr.L.Warder

Contact Information

pitproject.psychiatry@gmail.compitproject.ca

Website• Webinar• Introductory lecture

– Advertisement– Film– Slides for handouts– Attendance list– Evaluation form

Website

Getting started• Preamble• Overview• DERRS scale to consider for monitoring• Informing your clinic

– Referring Doctor Info Sheet– Patient Information Page– Presentation for those delivering care

Thankyou!

Questions?